Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clear View Sanitarium during CMS and state inspections, most recent first.
Unsafe food storage and labeling practices were observed in the kitchen when a dented can of pineapple chunks was stored with regular cans in the dry storage area and prepared items, including thickened water and orange juice, were left on a tray without a use-by date label. The DSS acknowledged the dented can should have been kept in a designated area, and the DON stated food items should be labeled with received and expiration or use-by dates.
A resident with schizophrenia, dementia with psychotic disturbance, and chronic viral hepatitis C had a proposed transfer/discharge notice that was incomplete. The notice lacked required items such as the notification date, effective date, discharged location, reason for transfer/discharge, LTC Ombudsman notification date, and signature dates/signatures. RN and DON interviews confirmed the form was not fully completed, and the facility policy did not list the required notice elements or Ombudsman notification procedures.
A resident with respiratory failure, DM, and HTN had a quarterly MDS completed late. The MDS showed impaired cognition and need for supervision with dressing and personal hygiene, and the MDSN confirmed the assessment was completed beyond the required 92-day timeframe. The DON stated late MDS completion can cause late payment and inaccurate resident data.
Inaccurate MDS Assessment Failed to Code Antibiotic Use: A resident with psychosis, depression, and DM had severe cognitive impairment and needed substantial assistance with ADLs. The resident received Macrobid for a UTI, but the MDS Nurse confirmed the MDS did not code the antibiotic in Section N0415 despite the medication being given within the 7-day look-back period, making the assessment inaccurate and affecting CMS data and quality measures.
A resident with psychosis, depression, and DM had impaired decision-making capacity, severe cognitive impairment, and required substantial assistance with personal care. The resident was prescribed Seroquel for psychosis with aggressive behavior, but the facility relied on an older PASARR Level 1 screening from another facility that showed no SMI and no psychotropic meds. The DON stated a new PASARR Level 1 screening should have been completed and resubmitted based on the resident’s current diagnoses and medication use.
A resident with ESRD receiving dialysis 3x/week had a care plan intervention requiring the dialysis E-KIT to always be available at bedside, but RN found the kit stored at the nurse station instead. RN confirmed the care plan was not followed and stated the kit should be at bedside for easy access in an emergency or if bleeding occurred at the access site. The resident also had dementia and psychosis, and the H&P stated the resident lacked capacity to understand and make decisions.
Care Plan Not Updated for Bolster Pad Use: A resident with Alzheimer's disease, dementia, and osteoarthritis had severe cognitive impairment and was dependent on staff for multiple ADLs. RN and DON review showed the fall care plan did not include the use of bolster pads, and the DON acknowledged the care plan should have been revised when the intervention was implemented. The facility policy stated care plans shall be updated when needed and as the resident's condition or needs change.
Open and Overfilled Trash Dumpster: Surveyors observed one outside trash dumpster with its lid open and filled with trash. The DSS acknowledged the dumpster was open and overfilled and stated the lid should be closed at all times. The DON also stated the facility had a prior deficiency for an open trash dumpster and that open trash bins attract unwanted pests.
A facility failed to resubmit a PASRR for a resident diagnosed with bipolar disorder, PTSD, and depression. The initial PASRR Level 1 screening incorrectly indicated no mental health disorder, despite documented diagnoses. Interviews with the RCC and DON confirmed the oversight, acknowledging the need for a resubmission as per facility policy.
A resident was prescribed Seroquel, an anti-psychotic medication, to manage dementia symptoms without a mental illness diagnosis. The resident's MDS assessment showed moderate cognitive impairment but no psychosis or behavioral symptoms. A nurse confirmed the prescription was for dementia behaviors, acknowledging the risk of falls from such medication use.
The facility did not have a room thermometer in the medication storage room to monitor and record temperatures, as observed during an interview with the DON. The absence of a thermometer and a logbook for room temperatures was noted, with the DON stating that maintenance would be contacted if the room felt too warm or cold. This deficiency could affect medication efficacy due to improper storage conditions.
The facility failed to remove a spoiled bag of cilantro from the walk-in refrigerator, which was found with brown leaves and liquid. The Dietary Supervisor acknowledged the cilantro was expired and should be removed but could not specify the consequences of consumption. This oversight posed a risk of foodborne illness for residents.
The facility failed to keep dumpsters closed and contain all trash, potentially attracting rodents. During an observation with the DS, both dumpsters were open, one was overflowing, and three uncovered bins with loose trash were in front of the dumpsters. The DS confirmed that dumpsters should be closed to prevent attracting animals.
Unsafe Food Storage and Missing Use-By Labels
Penalty
Summary
Safe and sanitary food storage and preparation were not maintained in the kitchen when a dented can of pineapple chunks was found mixed with regular non-dented cans in the dry storage area. During interview, the Dietary Service Supervisor acknowledged the dented can was placed on the same shelf as the regular cans and stated it was unacceptable, that dented cans should be placed in a designated area, and that the food inside the dented cans was no longer safe to consume. The facility policy titled Food Production and Storage stated that a separate defined storage area is provided for dented/rusted cans. The facility also had prepared food items in the kitchen that were not labeled with a use-by date. An observation found 6 cups of 8 oz thickened water and 1 cup of 8 oz orange juice on a tray with a sticker showing they were prepared on 2/23/2026, but no use-by date label was present. The DSS stated prepared food items should be labeled with the date prepared and the use-by date, and the DON stated all food items should be labeled with received date and expiration date or use-by date. The facility policy stated leftover food must be covered and labeled with the name of the item and the date prepared, but it did not address the need for a use-by date.
Incomplete transfer/discharge notice
Penalty
Summary
The facility failed to ensure that the written Notice of Proposed Transfer/Discharge for one resident contained the required content elements. Resident 75 was admitted with diagnoses including schizophrenia, dementia with psychotic disturbance, and chronic viral hepatitis C. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated moderate cognitive impairment in daily decision making. The MDS also showed the resident needed set-up or clean-up assistance for several ADLs and was independent for positioning, transferring, and walking. During interview and record review, staff reviewed the Notice of Proposed Transfer/Discharge and found it incomplete. One version lacked the notification date, effective date, discharged location, date sent to the LTC Ombudsman, reason for the transfer/discharge, and signature dates of the facility representative and resident/representative. A later version included the discharged location, discharge date, and an electronic signature by RN 1, but still did not include the date sent to the LTC Ombudsman, the reason for the transfer/discharge, or the resident/representative signature. RN 1 stated the form was automatically generated from the facility’s electronic system and that she only signed it. The DON acknowledged the notice was incomplete and stated staff discharging the resident were responsible for ensuring the notice was complete. The facility’s Transfer/Discharge Policy did not identify the federally required content elements for the written notice and did not include procedures requiring notification to the LTC Ombudsman at the time of a proposed transfer or discharge.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that Resident 4’s quarterly MDS assessment was completed within the required timeframe. Resident 4 was admitted with diagnoses including respiratory failure, DM, and HTN, and the H&P dated 7/19/2024 stated the resident did not have the capacity to understand and make decisions. The MDS dated 7/18/2025 showed moderately impaired cognitive skills for daily decision making and that the resident required supervision with upper and lower body dressing and personal hygiene. During review of the CMS MDS 3.0 NH Final Validation Report, the assessment with ARD 7/18/2025 was identified as completed late. In a concurrent interview and record review, the MDSN stated the quarterly MDS had been completed for more than 92 days and should be completed within 92 days. The MDSN stated the facility did not follow the timeframe for MDS completion as indicated in the RAI, and that late completion would result in billing errors and affect the care provided to residents. The DON also stated late completion of the MDS would result in late payment and inaccurate data of the resident’s condition. The facility policy stated quarterly assessments should be completed no less than every 90 days.
Inaccurate MDS Assessment Failed to Code Antibiotic Use
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident by not coding the resident’s antibiotic use in the recent assessment. Resident 3 was admitted and later readmitted to the facility with diagnoses including psychosis, depression, and diabetes mellitus. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS assessment indicated severely impaired cognitive skills for daily decision making, with substantial assistance needed for toileting hygiene, upper and lower body dressing, and personal hygiene. Resident 3 was prescribed Macrobid 100 mg by mouth twice daily for 5 days for treatment of a UTI, and the MAR showed the medication was administered as ordered. During interview and record review, the MDS Nurse stated the MDS assessment completed on 2/24/2026 was inaccurate because Section N0415 should have included the antibiotic use based on the 7-day look-back period, but it was not encoded. The MDS Nurse stated this was an oversight and that the inaccurate assessment affected the facility’s quality measures.
Failure to Re-submit PASARR Screening for Resident with Psychosis and Depression
Penalty
Summary
The facility failed to ensure that Resident 3’s PASARR Level 1 screening was completed and re-submitted after the resident’s condition changed. Resident 3 was initially admitted and later readmitted to the facility, and the record showed diagnoses of psychosis, depression, and diabetes mellitus. The resident’s H&P stated that the resident did not have the capacity to understand and make decisions, and the MDS showed severely impaired cognitive skills for daily decision making, with substantial assistance needed for toileting hygiene, upper and lower body dressing, and personal hygiene. The resident’s physician ordered Seroquel 75 mg by mouth daily and Seroquel 50 mg by mouth at bedtime for psychosis manifested by aggressive behavior, including pushing and swinging hands at staff during care. During interview and record review, the DON reviewed a PASARR Level 1 screening completed by another facility in 2023 and stated it showed no serious mental illness diagnoses and no psychotropic medications, with the case closed and no Level II evaluation required. The DON stated the facility should have completed and resubmitted a new PASARR Level 1 screening based on the resident’s psychosis, depression, and current psychotropic medication use, and that a positive Level 1 screen would trigger a Level II mental health evaluation.
Dialysis E-KIT Not Kept at Bedside
Penalty
Summary
The facility failed to ensure care plan interventions were implemented for a resident with ESRD who received dialysis three times per week. Resident 8’s physician order directed staff to observe the left forearm dialysis access site for drainage and bleeding, and the resident’s care plan for ESRD/dependence on renal dialysis included an intervention to make sure the dialysis emergency kit was always available at bedside. During an observation and interview in the resident’s room, RN 1 stated the dialysis E-KIT was not at bedside and was instead kept in a drawer at the nurse station. During a later interview and record review, RN 1 confirmed the care plan intervention was not followed and stated the kit should be kept at bedside so staff could easily access it in an emergency or if the resident had bleeding when removing the dressing. The resident’s record also showed diagnoses of ESRD, dementia, and psychosis, and the H&P stated the resident did not have the capacity to understand and make decisions. The DON stated it was very important to follow care plan interventions because the care plan is a set of standardized care the facility staff provides to residents.
Care Plan Not Updated for Bolster Pad Use
Penalty
Summary
The facility failed to review, update, and revise the care plan to address the use of bolster pads for one resident. The resident was admitted and later readmitted to the facility and had diagnoses including Alzheimer's Disease, dementia, and osteoarthritis. The resident's H&P dated 12/30/2025 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 1/2/2026 indicated severe cognitive impairment in daily decision making. The MDS also showed the resident was dependent on staff for ADLs including oral hygiene, toileting, showering, dressing, and positioning. During a concurrent interview and record review on 2/26/2026, RN 1 reviewed the resident's fall care plans and stated the care plan did not include one for the use of bolster pads. RN 1 stated the care plan should have been revised to reflect the use of bolster pads when the intervention was implemented. During an interview on 2/27/2026, the DON stated care plans are revised quarterly and with any change of condition or new physician orders, and acknowledged the resident's care plan should have been revised to reflect the use of a bolster pad. The facility policy stated care plans shall be updated when necessary and as the resident's condition or needs change.
Open and Overfilled Trash Dumpster
Penalty
Summary
The facility failed to ensure that one of the outside trash dumpsters was kept closed and not overfilled. During an observation on 2/24/2026 at 9:30 a.m. outside the facility, surveyors observed one trash dumpster with its lid open and filled with trash. During an interview on 2/26/2026 at 9:25 a.m., the Dietary Service Supervisor stated the dumpster lid should be closed at all times and should not be overfilled, and acknowledged that the dumpster had been open and overfilled. The DSS also stated that open trash dumpsters can attract rodents and insects and provide a place for them to harbor. During an interview on 2/26/2026 at 10:23 a.m., the DON stated the facility had received a deficiency five years earlier for an open trash dumpster and stated that open trash bins attract unwanted pests to the facility.
Failure to Resubmit PASRR for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) assessment was resubmitted for a resident who had been diagnosed with mental health disorders, including bipolar disorder, PTSD, and depression. The resident's PASRR Level 1 screening incorrectly indicated that the resident did not have a mental health disorder. This discrepancy was identified during a review of the resident's face sheet and diagnosis list, which showed the presence of these mental health conditions upon admission. Interviews with the Resident Care Coordinator (RCC) and the Director of Nursing (DON) revealed that PASRR assessments are required before admission and upon any change in a resident's condition. Both the RCC and DON acknowledged that a PASRR should have been resubmitted for the resident, as the initial screening results were negative despite the resident's documented mental health diagnoses. The facility's policy mandates a Level 2 review for residents with newly evident or possible serious mental disorders, which was not followed in this case.
Inappropriate Prescription of Anti-Psychotic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 30, was not prescribed Seroquel, an anti-psychotic medication, to control dementia symptoms without a diagnosis of a mental illness. Resident 30 was admitted with diagnoses including dementia, diabetes, and hypertension. The Minimum Data Set (MDS) assessment indicated that the resident's cognition was moderately impaired, but there were no indicators of psychosis or behavioral symptoms. Despite this, the resident was prescribed Seroquel 50 mg three times a day for dementia with behavioral disturbances, specifically striking out. During an interview and record review, a registered nurse confirmed that Resident 30 did not have a diagnosed mental illness and was taking Seroquel to control dementia behaviors. The nurse acknowledged that administering an anti-psychotic to an elderly person with dementia could be harmful, as it increases the risk of falls. This practice put Resident 30 at risk of an adverse reaction from taking an anti-psychotic medication without a proper diagnosis of a mental illness.
Medication Storage Room Lacks Temperature Monitoring
Penalty
Summary
The facility failed to ensure that the medication storage room was equipped with a room thermometer to monitor and record the temperature, which is necessary to maintain a safe environment for medication storage. During an observation and interview with the Director of Nursing (DON), it was noted that there was no room thermometer present, and the DON was unaware of its location following a reorganization of the room. Additionally, there was no logbook available to record room temperatures, as the facility only maintained a log for the refrigerator. The DON mentioned that maintenance would be called to check the room temperature if it felt too warm or cold. This oversight had the potential to compromise the effectiveness of medications due to improper storage conditions.
Spoiled Cilantro Found in Walk-in Refrigerator
Penalty
Summary
The facility failed to ensure that the walk-in refrigerator did not contain spoiled food, specifically a bag of cilantro. During an observation and interview with the Dietary Supervisor (DS), a bag of cilantro was found with brown leaves and brown liquid at the bottom, indicating spoilage. The bag was labeled with a received date, and the DS acknowledged that the cilantro was expired and should be removed, stating it was not safe to eat. However, the DS was unable to articulate the potential consequences if a resident consumed the expired cilantro. This oversight had the potential to result in foodborne illness for any resident consuming the spoiled cilantro.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that dumpsters were kept closed and all trash was properly contained, which had the potential to attract rodents to the trash area. During an observation and interview with the Dietary Supervisor (DS) at the dumpster area, it was noted that both dumpsters were open, and one was overflowing. Additionally, three uncovered gray bins containing loose trash were placed in front of the dumpsters. The DS acknowledged that the dumpsters should be closed at all times and stated that leaving them open could attract animals.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,405 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gardena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clear View Convalescent Center | 0 mi | ★★★★★ | 4 | 0 |
| Memorial Hospital Of Gardena D/p Snf | 0.3 mi | ★★★★★ | 13 | 0 |
| Kei-ai South Bay Healthcare Center | 0.7 mi | ★★★★★ | 17 | 0 |
| Gardena Convalescent Center | 0.8 mi | ★★★★★ | 16 | 0 |
| Rosecrans Care Center | 1.1 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Clear View Sanitarium.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.